As nurse practitioners take on increasingly responsible roles in practice, it is worthwhile to review how the education, certification, licensure, and practice have evolved over the past 55 years to become highly regulated like other practitioners.
The Society of Critical Care Medicine (SCCM) recognizes and values the contributions of each member of the healthcare team to deliver high-quality care to critically ill patients. As nurse practitioners (NPs) take on increasingly responsible roles in practice, it is worthwhile to review the educational process of these valued professionals. Physician and NP education differ, with each playing a different role in our healthcare system.
The role of the NP was developed in the mid-1960s at the University of Colorado by Loretta Ford, EdD, RN, and Henry K. Silver, MD, in response to physician shortages, with the first master’s program established at Boston College in 1967.1 NPs expanded into the intensive care unit (ICU) in the setting of residency shortages in the mid-1990s. By 1995, the first certification examination was offered for acute care NPs.1
In 2007, the Advanced Practice Registered Nurse (APRN) Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee developed the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE).2 The LACE model defined four APRN roles (including NPs) and education in at least one of six specific population foci (family/lifespan, adult gerontology, neonatal, pediatrics, women’s health, psychiatric mental health) to ensure that education and certification are valid and reliable. Notably, the process is nationally accepted and recognized as creating uniformity for licensure across the nation.
The LACE model effectively set forth APRN regulation with endorsement from 48 nursing organizations, including certifying, educational, and regulatory bodies. Most states now require NP certification and continuing education mandates for licensure to address competency.
There are now approximately 500 programs educating NPs (many at the doctoral level). Accredited programs in schools of nursing typically include the standards for nurse practitioner education, for example, those published by the National Task Force For Quality Nurse Practitioner Education3 or the American Association of Colleges of Nursing4 in their curricula. These programs include didactic learning as well as a minimum number of designated clinical hours based on the program of population foci. Upon programmatic completion, nurse practitioners are prepared for certification, subsequent licensure, and practice.
Some states mandate that education, certification, and practice align. For example, if a pediatric NP is educated in acute care, they must be certified as an acute care pediatric NP and practice in a pediatric acute care setting. This would disallow an NP educated as a family NP to practice in an ICU. However, since this is not mandated in all states, the hiring institution is responsible for ensuring that the NP is qualified and has the appropriate credentialing and privileging, just as it would for any other practitioner in the institution. When this process fails, whether for NPs, physician assistants (PAs), or physicians, patients are at risk.
Postgraduate education and training are important for integration of the NP into the ICU setting, and some hospitals offer fellowship programs.5 These programs vary in length and may or may not be accredited. One notable program is the Emory Critical Care Advanced Practice Provider (APP) Fellowship, originally conceived and designed by SCCM members Heather Meissen, DNP, ACNP, ARPN, FCCM; Rob Grabenkort, PA-C, MCCM; and Timothy Buchman, MD, PhD, MCCM. This program started in 2012 and has since provided postgraduate training for approximately 100 APPs. The one-year fellowship is accredited by the ANCC as a Practice Transition Program with Distinction.6
While postgraduate fellowship may be excellent, there are currently too few programs. However, other ICUs offer integration and training through onboarding or orientation models for new graduate NPs to ensure success in the role with keen attention to quality outcomes and patient safety.
Because of the variability in bringing NPs into ICU practice, it is important to evaluate outcomes associated with their care. In 2019, Kreeftenberg et al published a systematic review and meta-analysis that found no difference in mortality or ICU or hospital length of stay between care delivered by APPs and residents/fellows.7 A concise review published in the same year noted contributions of APPs to high-quality patient care in ICU management, quality improvement, patient safety, financial impact, and resident education.8
In 2021, Gigli et al presented outcomes associated with APP practice in pediatric critical care.9 Using a database to complete a retrospective cohort, the authors identified decreased odds of hospital-acquired infections in ICUs with APP staffing. Interestingly, the study also found no change in mortality, although the patients admitted to the ICUs with APPs were sicker than in non-APP ICUs. These few articles provide some information on outcomes associated with APP care. It is important to note that separating NP and PA outcomes may be challenging as many teams are integrated despite different training before entering the workplace (for more studies, visit
Critical Care Medicine and search “
nurse practitioners” or “
advanced practice providers”).
In summary, NP education, certification, licensure, and practice have evolved over the past 55 years in the United States and are highly regulated, similar to those of other practitioners. NPs working in ICUs around the globe function in a variety of ways, varying even from ICU to ICU within the same hospital, and these models continue to evolve to meet the needs of the patients and healthcare system. While it may be easy to select cases to highlight, expose, and subsequently blame the failure on one piece of the system, I suggest clear analysis of the contributing variables and a systems approach to improvement because we are all human and can make a mistake at any time. I am proud that SCCM continues to be the beacon of light in multiprofessional healthcare by recognizing the value and contributions of each professional member of the team to produce high-quality patient outcomes.
References
1. LSU Health New Orleans. School of Nursing. About nurse practitioners. Accessed September 23, 2024. https://nursing.lsuhsc.edu/NP/aboutnursepractitioners.aspx#:~:text=Subsequently%2C%20the%20first%20national%20certification%20for%20the,acute%20care%20NPs%20was%20administered%20in%201995
2. APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. July 7, 2008. Accessed September 13, 2024. https://www.aacnnursing.org/Portals/0/PDFs/Teaching-Resources/APRNReport.pdf
3. National Organization of Nurse Practitioner Faculties. National Task Force (NTF) Standards. Accessed September 23, 2024. https://www.nonpf.org/page/NTFStandards
4. American Association of Colleges of Nursing. The Essentials. Accessed September 23, 2024. https://www.aacnnursing.org/essentials
5. Sorce L, Simone S, Madden M. Educational preparation and postgraduate training curriculum for pediatric critical care nurse practitioners.
Pediatr Crit Care Med. 2010 Mar;11(2):205-212.
6. Emory University Critical Care Center. Critical Care APP Fellowship. July 1, 2024. Accessed September 13, 2024. https://criticalcarecenter.emory.edu/education/app-fellowship/app-fellow-home.html
7. Kreeftenberg HG, Pouwels S, Bindels AJGH, de Bie A, van der Voort PHJ. Impact of the advanced practice provider in adult critical care: a systematic review and meta-analysis.
Crit Care Med. 2019 May;47(5):722-730.
8. Kleinpell RM, Grabenkort WR, Kapu AN, Constantine R, Sicoutris C. Nurse practitioners and physician assistants in acute and critical care: a concise review of the literature and data 2008-2018.
Crit Care Med. 2019 Oct;47(10):1442-1449.
9. Gigli KH, Davis BS, Martsolf GR, Kahn JM. Advanced practice provider-inclusive staffing models and patient outcomes in pediatric critical care.
Med Care. 2021 Jul;59(7):597-603.
